Needle aponeurotomy, Dupuytren's, contracture, presentation at ASSH
PRESENTATION AT THE AMERICAN SOCIETY OF SURGERY OF THE HAND ON NA(Subcutaneous or Needle Fasciotomy)
Sept. 8, 2006 Washington, DC
1 A New Look At An Old Solution: Closed (Needle) Fasciotomy
By Keith Denkler, M.D.
Associate Clinical Professor of Plastic Surgery, UCSF
Limited fasciectomy with, or without grafting, or open techniques (McCash) remains the treatment of choice for Dupuytren’s contracture since the 1960’s
3 What is the Reconstructive Ladder of Treatment for Dupuytren’s?
4 Dupuytren’s Solutions
Medications or creams: Not yet
Injections Kenalog, collagenase (pending)
Skeletal traction before, or after surgery can help, but invasive
Surgical Release via perforations-Fasciotomy
Open or closed types
Small knives or needles may be used
Surgical Removal via excision-Fasciectomy
Localized, limited, or radical fasciectomies
With full-thickness skin graft (dermofasciectomy)
5 NEEDLE FASCIOTOMY: History and Complications
Subcutaneous fasciotomy was advocated/performed? by Cline 1777 and Cooper in 1822 (first fasciotomies)
Dupuytren 1832 Preferred transverse fasciotomy leaving the skin open
Goyrand 1833 proposed longitudinal subcutaneous fasciectomies with suturing to prevent infection (first limited fasciectomy)
6 "Late 19th surgeons liked the reduced chance of infection and results with closed fasciotomy
Adams 1878 and 1890 published two books on this subcutaneous release
7 Radical Fasciectomy
Technical improvements in surgery and anesthesia allowed in the early 20th century surgeons more extensive removal of diseased Dupuytren’s fascia to prevent recurrence
Keen (1906) and Iversen (1909)
Lexer (1931) and McIndoe 1948, McIndoe and Beare 1958
8 Limited Fasciectomy
Extensive post-operative complications led to development of the current limited fasciectomy as recurrence rates are reported to be similar
Hueston 1962 and others
First limited fasciectomy by Goyrand 1833
9 Surgery for Dupuytren’s: Fasciectomies; How are we doing?
Personal fifty-year review on Dupuytren’s surgery
Significant and major injuries may occur after surgery
Are we helping our patients with fasciectomies: yes
Are we hurting our patients with fasciectomies: yes
10 Overall Risk of Digital Nerve Injury
Surgical fasciectomy operations carry a 3% risk of digital nerve injury despite a bloodless field, skilled surgeons, loupe magnification, and an open approach
Tubiana 7.7% of 195 surgeries in 1967 to Coert 7.7% of 558 surgeries in 2006
Major number of cases in the review
Geldmacher 2.8% of 2160 in 1994
McFarlane 1.5% of 1339 in 1990
Overall numbers over 50 years 3.2% out of 6,038 reported in the personal series (Range 0.4% to 7.8%)
Incidence in recurrent cases usually much higher Sennwald 27% of 26 repeat operations in 1990 sustained nerve damage
11 Risk of Digital Artery Injury
If two are injured, may require revascularization or lead to secondary necrosis or gangrene
Major problem before surgery for recurrent disease
Overall rate counting unreported as zero is 0.8% out of 6,038 surgeries in 50 year review
12 Risk of Infection
Most small to moderate, but may be severe despite aseptic technique and antibiotics
Range of infections is 0 to 9.6%
Major number of cases in the review
Geldmacher 2.6% of 2160 in 1994
McFarlane 1.3% of 1339
Overall rate 2.4% of 6038
13 Risk of Hematoma
Formerly a major complication due to more undermining of flaps 15.8% of Tubiana’s series in 1967!
Geldmacher 1994 1.16 of 2160
McFarlane 2.2% of 1339
Overall risk 2.1% of 6038 surgeries in 50 year review
14 Reflex Sympathetic Dystrophy and Dupuytren’s Surgery
Highly morbid disease requiring difficult, prolonged, and usually disappointing treatment
Geldmacher 2.2% of 2160
McFarlane 4.2% of 1339
Overall incidence 3.5% of 6038 surgeries in 50 year review
15 Reflex Sympathetic Dystrophy and Dupuytren’s Surgery
Very rare in NA Probably because of use of local anesthetic
Use of general anesthetic increases risk of RSD!
Incidence may be reduced in with more use of axillary block anesthesia in study published this year
Reuben, S.S., et al., The incidence of complex regional pain syndrome after fasciectomy for Dupuytren's contracture: a prospective observational study of four anesthetic techniques. Anesth Analg, 2006. 102(2): p. 499-503.
16 Skin Slough or Separation
Complication of cutting and undermining
Geldmacher 1994 4.7% of 2160
McFarlane 1990 4.7% of 1339
Overall incidence is 5.4% of 6038
Dupuytren’s limited fasciectomy under local anesthesia with epinephrine, my own paper, had a 5% incidence:
17 Unusual and or Bad Complications of Dupuytren’s Surgery
Hospital re-admission up to 15% incidence
Mandol in UK 2005 Ann RCS
Medical perioperative complications
Tendon injury 0.23% Geldmacher 1994
Digital gangrene 0.1% McFarlane 1990
Prolonged edema and stiffness may occur
Scar sequelae (incisions too straight) Too frequent?
18 Complications of NA
Usually minor complications
Skin tears Could need sutures
More significant complications
Digital nerve injury approx 1%
Reflex Sympathetic Dystrophy Rate?
19 Complications of NA
Digital nerve injury
1% of 473 overall cases in published series by hand surgeons
JHS (Am) Rijssen 2006
JHS (Br) Foucher 2001
French data Lermusiaux 1997 and 2001
Large numbers (50,000) are anecdotal and not part of series States “nerve as rare as tendon” and “five tendons out of 50,000”
20 Complications of NA
Summarized by Foucher 2001
May be a large number of unreported complications We do not really know the denominator
Foucher 2001 references
Badois data from 1993 3736 aponeurotomies
Two tendon injuries or 0.05% Two nerve injuries or 0.05%
21 My Own Complications 443 Digits
Digital nerve injury 4/443 or 0.9% (one case was after previous surgery for recurrent disease)
A few patients developed temporary neuropraxia from nerve “stretching”
Flexor tendon injury 1/443 or 0.2% (case #20 -60 degrees PIP)
Infection 5/443 or 1.1% (two severe in/around PIP joint 2 severe were recurrent PIP disease needing needle capsulotomies of the PIP joint
22 My Own Complications 443 Digits: RSD
1/443 or 0.2% incidence of Reflex Sympathetic Dystrophy
(patient had previous surgery and RSD after previous surgery)
A second RSD from previous surgery did not develop RSD after my NA procedure!
Skin tears Sutured 10/443 or 2%
Minor, from stretching skin approx 10% and not sutured
FTSG in 1/443 or 0.2% stage 4 finger -145 MCP+PIP total loss of extendion
23 Can We Do Better?
There is no one operation for Dupuytren’s!
Can we take the old, add the new, and help our patients by doing less?
Why not start small?
Repeat as necessary!
TABLE OF LITERATURE ON DUPUYTREN'S SURGERY
Historical Comments on Subcutaneous Release (Fasciotomy) of Dupuytren's Contracture
Binnie in 1917: “subcutaneous section is usually followed by recurrence, but the recurrence may be so delayed and the operation is so trivial that many patients prefer repeated section to a more formidable radical operation”
Luck from 1959: "Subcutaneous fasciotomy was first suggested for the treatment of flexion contracture of the fingers by Sri Astley Cooper in 1822. He wrote "... but when the aponeurosis is the cause of the contraction and the contracted band is narrow, it may be with advantage divided by a pointed bistoury, introduced through a very small wound in the integument. The finger is extended and a splint is applied to preserve it in a straight position". This procedure fell into disrepute through the years because it was indiscriminately applied to all cases of contracture; but Luck has recently reintroduced it and it has achieved limited popularity. Having perused 20 papers, published since Skoog's monograph in 1948, on the surgical treatment of flexion contracture, we find that fasciotomy is either not mentioned at all or condemned. The radical fasciectomy, on the other hand, is given not merely as the procedure of choice but is considered the only satisfactory surgical treatment. This blind adherence to a single procedure for the treatment of a disease that has many individual variations and several stages of development shows an infatuation with a technical exercise that does not properly answer each patient's need.
Howard outlined indications for fasciotomy:
1) as a preliminary to fasciectomy in severe cases, since it allows the palmar skin to stretch out before the fascia is excised
2) for older, retired, or non-working patients with limited palmar involvement and cords limited to one or two fingers
3) for skilled workers with palmar cords who cannot afford the loss of working time associated with fasciectomy, provided they understand that later fasciectomy or repeat fasciotomy will be necessary
4) for patients who have arthritis or who for other reasons are prone to joint stiffness
5) for patients who, because of other physical impairment, can only tolerate minor procedures.
McFarlane 1988 “no one method to treat Dupuytren’s contracture has been established. All methods are equally defensible. One’s choice of treatment becomes a decision based on training, technical skill, and one’s concept of the disease process.”
Neuropraxia has been reported even when the fasciotomy has been limited to the palm and has been attributed to overstretching of the finger after a severe contracture
Bryan confirms the findings of Colville (1983) and Rowley (1984) et al. who suggested that fasciotomy has a role to offer as a corrective procedure in those patients whose contracture is restricted to the MP joints and as a preliminary procedure in those with deformity affecting the PIP joint as well.”… It may also be stated that 57% of patients with deformity affecting mainly the MP joint will have maintained their correction at five years.
Other complications of Open Surgery for Dupuytren's
Digital gangrene 0.1%
Myocardial infarction, left ventricular failure, urinary retention
Arterial injury, gangrene, and amputation
Emergency revascularization[22, 23]
Secondary amputation 1.30% as a result of malperfusion from divided arteries 
Tendon injury 0.23%
Inclusion cyst 1.3%
Scar sequelae 1.2% 
Foucher commenting on needle aponeurotomy:
Of 65 hands reviewed at an average of 2.5 years, 54% had recurrent lack of extension and 11% necessitated a second surgery procedure for recurring contracture. From his experience, Foucher states that the best indications for this technique are visible cords adhering to the skin (such as palmar pretendinous cords and digital central cords), whereas retrovascular cords are too dangerous to deal with using this technique. He advises using the technique in the early stages of the disease (where one would usually advise the patient to wait for an aggravation of the contracture before performing a fasciectomy), in women (because of the increased risk of RSD with fasciectomy), and in an old or unhealthy patient. He advises against the use of this technique in recurrences after surgery (where the anatomical relationships of the neurovascular bundles may have been greatly modified) and in severe forms in your adults where the dermofasciectomy is best indicated.
Recurrence and extension modified from Geldmacher
Notes on recurrence from Leclercq:
Mantero et al. (1986) followed their patients for up to 30 years and reported a global rate of 63% recurrence
Norotte et al. (1988) followed 58 patients for more than 10 years. Of 69 hands operated on, 71% had recurrence after 10 years.
Foucher et al.’s series (1992) showed a lower incidence of recurrences (46%) but his 54 patients were reviewed at 5.6 years on average
An average of 30% of patients experience a recurrence during the first and second postoperative years, then another 15% during the 3rd to 5th years, 10% between 5 and 10 years, and less than 10% after 10 years. Thus, even though patients are free of recurrence at 5 years, there is still a 10-15% chance that they develop one later on. From Norotte et al.’s series it appears that the most severe recurrences (Stages II and above in Tubiana’s grading) occurred early, whereas recurrences appearing later usually remained discrete (Stages I or II).
RSD or complex regional pain syndrome occurs more from general or bier block anesthesia for Dupuytren’s than axillary block anesthesia:
Significantly (P < 0.01) more patients developed postoperative CRPS in the general anesthesia group (n = 25; 24%) and the (IVRA Bier Block) lidocaine group (n = 12; 25%) compared with either the axillary block group (n = 5; 5%) or the IVRA lidocaine and clonidine group (n = 3; 6%)
Hospitalization rate of 14.5% after limited fasciectomy for Dupuytren’s as an outpatient surgery. Usually bleeding or nausea and increased risk factors included males, age over 80, BMI over 30, surgery lasting greater than 45 minutes, or a surgical delay over 2.5 hours.
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